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March 17, 2015

The ProMISe study was published in NEJM today -- I'm sure there will be great takes from all around. The first I saw was from Rick Body at St. Emlyn's, very nice summary indeed.

I'll leave the detailed analysis to others. My quick take, mostly based on comparing baseline characteristics of each group (Table 1), interventions in each group (Table 2), and outcomes (Table 3): ProMISe is a lot like ProCESS and ARISE.

The groups were similar, and the outcomes were similar, but most notably, the interventions were similar.

My bottom line interpretation remains the same; the keys in sepsis are:

early identification

early antibiotics

early aggressive resuscitation (particularly fluids)

We've gotten much better at all of those since 2001, which is (in my opinion) the main lesson from Rivers.

What ProCESS, ARISE, and ProMISe really tell us is that if you do all the things that are on a protocol, it doesn't matter whether or not you have a protocol.*

Like with ProCESS, it's a little tricky to decipher what fluids each subgroup actually got. I think Table S7 in the Supplemental Appendix is key:

February 10, 2015

My wife is a dietitian and a very good, healthy cook. Today she was cooking some Brussels sprouts (which I, evidently incorrectly, have been calling "brussel sprouts") and it brought up a great lesson in how hard it is to try to eat healthily in America. Rather, I just finished 26th grade and my wife went to school for this and has literally done this for a living for nearly a decade, and yet we can't figure out what we're eating.

We have a 1-pound bag of Brussels sprouts:

1 pound bag = 454 grams

According to the label, the serving size is 4 sprouts, or 84g, which contains 40 calories. There are 5 servings per container, which should be 20 sprouts in the bag for a total of 200 calories.

The label (photo) is identical to the official USDA label (image above).

My wife counted how many sprouts came in the bag, and we have 40, not the 20 the label says we should have (4 sprouts per serving x 5 servings). Which, on the one hand, is great, because, hey, who doesn't want free Brussels sprouts?

So does our bag just have really small sprouts? Or do we have a 400-calorie bag of Brussels sprouts?

4 of our sprouts in a 1-cup measuring cup

10 of our sprouts in a 1-cup measuring cup

This looks like <4 servings, probably closer to 3 with the (inedible) stems cut off

So how do we figure out the nutrition content? Do we have 10 servings of Brussels sprouts and there are 400 calories? Or, do use our measuring cup and we have 160 calories?

My point here isn't that I want bigger sprouts, or "hey look the Brussels sprouts people don't know how to do math!" But again, I just finished 26th grade and my wife went to school for this and has literally done this for a living for nearly a decade, and yet we can't figure out what we're eating.

Traditionally outpatient care has been split between physician offices or hospital outpatient departments (OPD). Recent years have seen a number of incentives pushing hospitals to buy up physician practices (and physician practices to consolidate into hospital systems) and one of them is that as OPD, the hospital can charge more than the physician did. The physician share ends up being a bit smaller than before (see chart page 32 in this MedPAC summary) but now the hospital system can charge a facility fee in addition to the doc's professional fee (evaluation and management, or E/M) so the total payment is bigger. The doc gets less but gets all the benefits of being in the hospital system (brand, stability, infrastructure, etc) and the hospital gets money & a referral network, all for doing little less than flipping a sign on the front door (to steal directly from Atul Grover).

The rub here is that the higher payments to OPD basically used to be a hidden but legitimate subsidy to safety net hospitals (using the term loosely); broadly speaking, OPDs were part of bigger, underfunded hospitals serving poorer populations. Now, hospitals that operate on the different end of the nonprofit spectrum are cashing in a bit. There's definitely some abusive practices now, but how do we throw out the bathwater without the baby? I'd like to think that if we want to subsidize hospitals that serve poor patients we should just do that outright, but, well, Gruber got in trouble for explaining how that works.

There's a lot of parallel to the issues with the 340b system, except that is an explicit, not implicit subsidy.

For those of you have have listened to the podcast on clinical decision rules, please fill out this second 2 question, 15 second survey, after which you will be given a link to a free bonus podcast with Ian Stiell discussing the new Atrial Fibrillation guidelines!

December 11, 2014

Some of our EM Colleagues are evaluating the impact of Social Media on knowledge uptake. They’ve designed an audio message from EBM guru Ian Stiell (embedded below) and very short (~2 minutes) pre-survey.
At the end of the survey you’ll be provided with access to a 1-hour EM Cases podcast by Anton Helman featuring Ian Stiell discussing “Clinical Decision Rules and Risk Scales”